Symptoms Versus Impairment

Abstract

Diagnosing ADHD based primarily on symptom reports assumes that the number/frequency of symptoms is tied closely to the impairment imposed on an individual's functioning. That presumed linkage encourages diagnosis more by Diagnostic and Statistical Manual of Mental Disorders (4th ed.) style symptom lists than well-defined, psychometrically sound assessments of impairment. The current study correlated measures reflecting each construct in four separate, large-scale ADHD research samples. Average correlation between symptoms and impairment accounted for less than 10% of variance. Symptoms never predicted more than 25% of the variance in impairment. When an ADHD group was formed according to a measure of current symptoms, the sample size shrunk by 77% when a criterion-based measure of impairment was added. The partial unlinking of symptoms and impairment has implications for decisions about the diagnostic process, research criteria for participant inclusion, prevalence estimates, gender ratios, evaluation of treatment effects, service delivery, and many other issues.

Severity of Children’s ADHD Symptoms and Parenting Stress: A Multiple Mediation Model of Self-Regulation

“…Our findings have significant implications for the clinical management of ADHD. First, similarly to the importance of assessing children with ADHD's functional impairment versus simply their symptoms (Pelham et al 2005;Gordon 2006), an evidence-based assessment of ADHD should include not only an overall assessment of the parents' stress but also what specific child behaviors are impairing the parents' functioning. Our results would suggest not only examining defiant/aggressive symptoms that have been previously documented as being a source of stress Johnson and Mash 2001) but also children's emotional lability and executive functioning difficulties.…”

Identifying ADHD Symptoms Most Associated with Impairment in Early Childhood, Middle Childhood, and Adolescence Using Teacher Report

“…However, more recent evidence from a short-term longitudinal study with a community sample of fourth, fifth, and sixth graders suggests that parent-rated IA, but not HI, was associated with lower peer acceptance and fewer dyadic friendships (Tseng et al 2014). Further, in adolescence and adulthood, HI may be related to negative outcomes associated with risky behaviors (e.g., arrests, car accidents) (Gordon et al 2006). Although speculative, the stronger association with HI may be largely accounted for by symptoms of impulsivity rather than traditional symptoms of hyperactivity.…”

“…Studies examining the relationship between impairment and ADHD subtype demonstrate some symptom-impairment specificity (e.g., Gordon et al 2006;Molina et al 2001). The patterns generally suggest that children with the IA subtype are more likely to experience academic impairment (e.g., learning disabilities, problems with school work), whereas children with the Combined (CB) subtype are more likely to experience behavioral impairment such as problems with peers, opposition and conduct problems (Barkley et al 1990;Garner et al 2013;Gaub and Carlson 1997;Graetz et al 2001;Langberg et al 2011;Willcutt et al 2012) and that this relationship may remain throughout childhood and into young adulthood (e.g., Gordon et al 2006;Molina et al 2001).…”

“…The patterns generally suggest that children with the IA subtype are more likely to experience academic impairment (e.g., learning disabilities, problems with school work), whereas children with the Combined (CB) subtype are more likely to experience behavioral impairment such as problems with peers, opposition and conduct problems (Barkley et al 1990;Garner et al 2013;Gaub and Carlson 1997;Graetz et al 2001;Langberg et al 2011;Willcutt et al 2012) and that this relationship may remain throughout childhood and into young adulthood (e.g., Gordon et al 2006;Molina et al 2001). Others have demonstrated predictive validity for the inattentive subtype of ADHD, as children who met symptom criteria for the ADHD-IA subtype exhibited lower achievement scores over 8 years than those without ADHD or who met symptom criteria for another subtype (Massetti et al 2008).…”

“…Thus, symptoms that are highly correlated with other symptoms have been identified without evidence that they are associated with impairment, which may limit their diagnostic efficiency. Indeed, research conducted in normative community samples indicates that many people meet the ADHD symptom criteria but are not impaired (e.g., Gordon et al 2006;Healey et al 2008) This is an important distinction, as impairment in functioning, rather than symptoms, is often the primary reason that a child is referred for services (Angold et al 1999). Further, improved functioning, rather than symptom reduction, has become a recommended target for intervention, given the relevance to consumers and later adjustment (see Pelham et al 2005 for review).…”